Reversing the "Risk‐Treatment Paradox" of Bleeding in Patients Undergoing Percutaneous Coronary Intervention: Risk‐Concordant Use of Bleeding Avoidance Strategies Is Associated With Reduced Bleeding and Lower Costs. Issue 21 (6th November 2018) - Amin, Amit P.
Abstract : Background: Bleeding is a common, morbid, and costly complication of percutaneous coronary intervention. While bleeding avoidance strategies (BAS) are effective, they are used paradoxically less in patients at high risk of bleeding. Whether a patient‐centered approach to specifically increase the risk‐concordant use of BAS and, thus, reverse the risk‐treatment paradox is associated with reduced bleeding and costs is unknown. Methods and Results: We implemented an intervention to reverse the bleeding risk‐treatment paradox at Barnes‐Jewish Hospital, St. Louis, MO, and examined: (1) the temporal trends in BAS use and (2) the association of risk‐concordant BAS use with bleeding and hospital costs of percutaneous coronary intervention. Among 3519 percutaneous coronary interventions, there was a significantly increasing trend ( P =0.002) in risk‐concordant use of BAS. The bleeding incidence was 2% in the risk‐concordant group versus 9% in the risk‐discordant group (absolute risk difference, 7%; number needed to treat, 14). Risk‐concordant BAS use was associated with a 67% (95% confidence interval, 52–78%; P <0.001) reduction in the risk of bleeding and a $4738 (95% confidence interval, 3353–6122; P <0.001) reduction in per‐patient percutaneous coronary intervention hospitalization costs (21.6% cost‐savings). Conclusions: In this study, patient‐centered care directly aimed to make treatment‐related decisions based on predicted risk of bleeding, led to more risk‐concordant use of BAS and reversal of the risk‐treatment paradox. This, in turn, was associated with a reduction in bleeding and hospitalization costs. Larger multicentered studies are needed to corroborate these results. As clinical medicine moves toward personalization, both patients and hospitals can benefit from a simple practice change that encourages objectivity and mitigates variability in care.